Student's Name ___________________________________ SS# or ID # _____________________________________
Address ____________________________________________________ Cell phone___________________________
1. Income earned in 2018 does not accurately reflect the student's and/or spouse's, and/or parents' current income
circumstances for one for the following reasons: (check all that apply)
Independent Student
____ a. loss of employment or change of employment status for student/spouse;
____ b. divorce/separation or death of a spouse;
____ c. loss of untaxed income;
____ d. disability of student/spouse;
____ e. unusual medical/dental bills or handicapped related expenses;
____ f. one-time income; (see item #3 below)
____ g. other unusual debt/expenses.
Dependent Student
____ h. parents' or student’s loss of employment or change in employment status;
____ i. divorce/separation or death of a parent;
____ j. loss of untaxed income (Social Security benefits, pension, etc);
____ k. disability of a parent;
____ l. unusual medical/dental bills or handicapped related expenses;
____ m. one-time income; (see item #3 below)
____ n. other unusual debt/expenses.
2. If (a, b, c, d) or (h, i, j, or k) is checked above, please complete the following chart using 2018 income
INCOME* Provide copy of 2019 Federal Tax return or 2019 yearly income documents:
Student Spouse or Parent
Wages, salaries, tips (Include severance pay, disability payments, etc.
Other taxable income (Unemployment Compensation, Worker’s Comp, Etc.)
Untaxed social security benefits
Public Assistance
Child Support Received
Other Untaxed Income
*If you or your parents are divorced or separated, give only your information or the information of the custodial parent.
*If loss of income was due to the death of a spouse or parent, give only your information or the information of your
surviving parent.
3. If (f) or (m) is checked, identify the source of income and explain how the funds were spent or invested. Explain below.
All of the information on this form and supporting documents
is true and complete to the best of my knowledge.
Student's Signature Date
Yes No
Financial Aid Officer Date
Loss of employment or change in employment status
Provide the following:
_____ a. ESD Monetary Determination - Form 508
_____ b. Letter from employer detailing termination date
_____ c. Unemployment papers and copy of last check stub reflecting year-to-date wage total.
Divorce, separation, or death of a spouse or parent:
Provide the appropriate W-2 form and one of the following:
_____ a. Copy of divorce decree
_____ b. Copy of legal separation papers
_____ c. Death certificate or death notice
Loss of untaxed income:
Provide a copy of letter from agency who provided benefits detailing termination of benefits and copies of
summaries of benefits.
Disability of student/spouse/parent:
Provide medical documentation of disability and document any benefits received as a result of the disability.
Unusual medical, or dental bills or handicapped related expenses:
Provide a copy of Schedule A of the Federal 1040 form or canceled checks or receipts showing amount
paid; include medical insurance premiums paid. (To be considered unusual, medical expenses must exceed
7.5% of 2015 adjusted gross income [AGI].)
One time income:
Document source and amount of income and verify use of income.
Other unusual debt/expenses:
Document the debt/expenses and include method of payment.